## TRANSMITTA LO FOMAH A LEA D SIT E PAIN T STABILIZATIO NFIL EFOLDE R SAI D # : 2^&,2. 7 Date : Address : c33/ 8 Maf>le . '^h LB PStabilizatio nContractor : PRUDEN T TECHNOLOGIES , INC . Year : 200 9 PAIN T STABILIZATIO N PROPERT Y FIL EFOLDE RDOCUMENT S A Video of property (DVD) : Pre-Stabilizatio n& Post-Stabilizatio nVideo s \ A Executiv e Summary A SignedAcces s Agreement For m A Advanc e Notic e For m A Pre-Stabilizatio nVide o Agreement Form A Acces s Trackin g For m y Property Acces s Assessmen t For m

.A Neighbo r Acces s Agreement For m \A Pain t Matc hForm y Pre-Stabilizatio nPropert y Safet y Assessmen t For m A Work-Site Hazard s Analysi s Checklis t A Photographs : Pre-Stabilizatio nPropert y Hazar dAssessmen t Photograph s \A Dougla s Count y Assessor Propert y informatio n y Propert y Completio nAgreement For mSignedb y Propert y Owne r y Propert y Close-Out Chec k Lis t SignedBy EPA Pruden t Technologies , Inc . Signatur e 

## ^jJ.yA ^ •^.s^.i.jJa.. ^ EP A Signatur e 3005531 0 

# liH l Superfun d 

### Dat e 

## Ih'^^Jc/ O Apit e ^TECHNOLOGIBS . INC . 

# Propert y Summar y Date : 11/~/200 9 LB PSTABILIZATIO NEP A CONTRAC T EP-R7-08-0 7 Mont hof : No v Property Address : 251 8 Mapl e St . SAI D # : 29827 A . Executiv e Summarv : a . Issue s Encountered : NON E b . Issue s Resolved : NON E c . Uniqu e Findings : NON E d . Othe r Relevant Information : i . Acces s Date : 9/17/2009 ii . Work Began : 10/05/2009 iii . Close-Ou t Date : 10/22/2009 B . Enclosures : 1 . Pre-Stabilizatio nVide o 2 . Post-Stabilizatio nVide o 3 . Signe dAcces s Agreemen t Form 4 . Advance-Notic e Form 5 . Pre-Stabilizatio nVide o Agreement Form 6 . Acces s Trackin g Form 7 . Propert y Acces s Assessment Form 8 . Neighbo r Acces s Agreemen t Form 9 . Propert y Pain t Matc hForm 10 . Pre-Stabilizatio nPropert y Safet y Assessment Form 11 . Work-Sit e Hazard s Analysi s Checklis t 12 . Pre - Stabilizatio nPropert y Hazar dAssessment Photograph s 13 . Dougla s County Assessor Propert y Informatio n 14 . Signe dPropert y Completio nAgreement Form 15 . Propert y Close-Ou t Chec k Lis t Signe dB y EPA

# V R ,lBS.TPiC . Prudent Technologies , Inc . (Prudent ) i s unde r contrac t (Contrac t #EP-R7-08-07 ) wit hth e U . S . Environmenta l Protectio n Agenc y (EPA ) t o stabiliz e LeadBase dPaint (LBP ) at anumbe r o f propertie s locate di nOmaha , Nebraska , includin g th e property locate da t "T. ^ ) 8 " Tr)<ayli » S t " Th e EPArequest s you r permissio nt o allo w Pruden t t o perfor mLB PStabilizatio nat thi s property . B y signin g thi s form , th e property owne r grant s permissio nt o Pruden t t o perfor mactivitie s relate dt o LB PStabilizatio nincludin g scrapin g pain t an d paintin g ofth e reference dproperty . Further , th e owner/tenan t verifie s that the y hav e receive dth e LB Ppamphle t "Renovat e Right. " B y signin g thi s documen t I agre e t o allo w a nEPAcontracto r t o conduc t asoi l cleanu p at m

y property followin g completio no f lead-base dpain t stabilization, ifth e soi l cleanu p ha s no t alread y bee nperformed . I understan dthat th e stabilizatio ncontracto r canno t provid e assurance s o f whic hcontracto r wil l b e boun dt o th e soi l cleanup . I fiirther understan dthat th e soi l cleanu p contracto r will mak e al l reasonabl e effort s t o addres s concem s that I , a s th e property owner , ma y hav e regardin g soi l cleanu p a t m

y property . [VI Yes , 1 hav e rea dan dunderstan dth e paragrap habove .

Signatur e o f Property Owne r 

# of/(7/ o 7

Date Ifyo u hav e any question s abou t th e LB Pstabilizatio nplanne dfor you r property , please contac t Prudent' s Custome r Reiations/Offic e Manage r for th e LeadBase dPain t Stabilization , Mrs . Shanno nHolt , at (402 ) 504-100 4 o r (402)812-0223 . General question s abou t th e Omah aLeadSite cleanu p canb e directe dt o th e EPAPubli c Informatio nCenter s at (402 ) 731 ­ 304 5 (Sout hOmah aoffice ) o r (402 ) 99 1 -958 3 (NorthOmah aoffice) . Propert y Acces s Grante dBy : 

### 2^/g < l7f r$rr-hCt» n ( MOt^etj/ ^ ) (Pleas e Prin t Name ) Property Owne r Signature : 

# ;fe=^- ^ (Signature ) 

# 0?//7/o f (Date )

808 0 War d Parkway , Suit e 40 5 250 5 N . 24' " Stree t Suit e 30 8 424 2 Medica l Drive , Suit e 425 0 Kansa s City , M O 6411 4 Omaha , Nebrask a 6811 0 Sa n Antonio , TX 7822 9 Phone:(816)363-370 3 Phone : (402)504-100 4 Phone : (210)822-958 8 Fax : (816 ) 363-370 7 Fax : (402)504-100 5 Fax : (210 ) 579-657 7TBOtn^OLOGIBS . IN C PROPERT YINFORMATIO N (T o b e complete d b yresiden t and/o rpropert yowne r— pleas e print ) RESIOENTNAME : \ j (k ( tX.lA' f Owne r Rente r RESIDEN TADDRESS : 

# ^si 8 r^o^\f i st

I F RENTAL , PROPERT YOWNE D BY : 

# ^ 1 - H^-JJ^ r f^yfTZ. OWNER' S MAILIN G ADDRESS ; OWNER' S TELEPHON E NUMBE R - HOME : (>//^l ) ^yi'-L^VlyNORK : t^t H 1 ^^Z - 5^? ? NUMBE R O F OCCUPANT S UNDE R 7 YEAR S OLD : H ^ NUMBE R O F OCCUPANT S 7 YEAR S OL D AN D OLDER :
NUMBE R O F CHILDRE N UNDE R 7 YEAR S OL D WHO M PLA YI N TH E YAR D FO R 5 HOUR S O R MOR E PE R WEEK : COMMENT S O R SPECIA L INSTRUCTIONS : (I.E . DOGS , ENTR YGATES , ETC. )

AUTHORITY FO RENVIRONMENTA LRESPONS EACTIONS : Ih e activitie s t o b e impiemente dby EP A under thi s agreemen l ar c pursuant to Seclio n10 4 ofCERCLA , 4 2 U.S.C . 9604 . EPA' s righ l o f acces s l o th e property i s provide dfo r i

nSeclio n104(e ) ofCERCLA , 4 2 U.S . C 9605(e) , whic hprovide s enu ^ fo r "determinin g th e nee dfo r response , o r choosin g o r takin g any respons e actio nunder thi s lille . or otherwis e enforcin g th e provision s ofth e title. "

808 0 War d Parkway , Suit e 40 5 250 5 N . 24' " Street , Suit e 30 8 424 2 Medica l Drive , Suit e 425 0 Kansa s City , M O 6411 4 Omaha , hiebrask a 6811 0 Sa n Antonio , TX 7822 9 Phone : (816 ) 363-370 3 Phone : (402)504-100 4 Phone : (210)822-958 8 Fax : (816 ) 363-370 7 Fax : (402)504-100 5 Fax : (210 ) 579-657 7TECHNOLOGIES . INC . 

## Advance dnotic e needed . Afte r signin g th e acces s yo u allo w Pruden t t o begi nLea dBase d Pain t Stabilization . Al l Plants , weed s an dan y vehicle s o r item s o n ope nporc h(enclose dporche s wil l NO T b e stabilized ) mus t b e remove dprio r t o stabilization . Al l Pet s mus t b e ou t o f yar ddurin g stabilization . Ho w muc hnotic e d o yo u nee dt o hav e abov e mentione dtask s completed ? Ifyo u ar e alandlor dyo u wil l nee dt o contac t th e tenan t a s Pruden t Technologie s wil l onl y infor myou . D o yo u hav e an y pet s tha t resid e i nyard ? vy<ac-o*,\ ­ 

# (^woctf ) Notic e needed : 

# . c y Numbe r t o cal l t o giv e notice : 5 7 ^ — -^S " z - 7 Who mw e ar e givin g notic e to : "^^ ac • Home Owner' s Signatur e 

# .y< ^

808 0 War d Parkway , Suit e 40 5 250 5 N . 24' " Street , Suit e 30 8 424 2 Medica l Drive , Suit e 425 0 Kansa s City , M O 6411 4 Omaha , Nebrask a 6811 0 Sa n Antonio , TX 7822 9 Phone : (816 ) 363-370 3 Phone : (402)504-100 4 Phone : (210)822-968 8 Fax : (816 ) 363-370 7 Fax : (402)504-100 5 Fax : (210 ) 579-657 7TECHNOLOGIES. ] 

## PRE-STABILIZATIO NVIDE O FORM 1 UNDERSTAN D THA T PRUDENT TECHNOLOGIE S WIL LB ECOMIN G OUT T O SHOO T A PRE-STABILIZATIO NVIDE O AT MY PROPERTY . TH EVIDE O I S JUS T A TOO LUSE D T O DOCUMENT TH ECURRENT PROPERT Y STATUS/CONDITION . A POS T VIDE O WIL LALS O B E SHO T PRIO RT O COMPLETIO NO FSTABILIZATION . OWNER S NAME : 

# F*7«?Z- y 51 - HAj-J-^f ' PROPERT Y ADDRESS : 2 5 I ^ r^evpl dS ^ BVID/SAID : Z ^ S * ^ 7 HOMEOWNER S SIGNATURE : ^^ ^ ^-^clet c S^f^.-vr^ , tnan^^c ) PRUDEN T REPRESENTATIV ESIGNATURE : ^ (>*• • — AN Y CONDITIO N fEE D T O B EAWAR EO FBEFORESHOOTIN G VIDEO : (I.E . PETS , NOTIC ENEEDED) : ^ y

808 0 War d Parkway , Suit e 40 5 250 5 N . 24' " Street , Suit e 30 8 424 2 Medical Drive , Suit e 425 0 Kansa s City , M O 6411 4 Omaha , Nebrask a 6811 0 Sa n Antonio , T X 7822 9 Phone : (816 ) 363-370 3 Phone : (402)504-100 4 Phone : (210)822-958 8 Fax : (816 ) 363-370 7 Fax : (402)504-100 5 Fax : (210 ) 579-657 7"nEOINOLOGIBS, ] 

## ACCES S INFORMATIO NTRACKIN GSHEE T BVID : Q,<^S2' ^ PROPERT Y ADDRESS : '},S} ^ />ri(Xjpl' ^ ^f~ Propert y Owne dBy : (I f he w propert y owner )

Owner s Phon e No's : Home : Work : Cell : Fax : ~ Acces s Contractor : AS WPDA ME S PEOthe r (Prudent ) DAT E TIM E ACCESSO R CONRAC T DETAI L 

# >^|/M^ ^ /gjfM 

# icz r

Comments :

808 0 War d Parkway , Suit e 40 5 250 5 N . 24* " Street , Suit e 30 8 424 2 Medica l Drive , Suit e 425 0 Kansa s City , M O 6411 4 Omaha , Nebrask a 6811 0 Sa n Antonio , TX 7822 9 Phone : (816 ) 363-370 3 Phone : (402)504-100 4 Phone : (210)822-958 8 Fax : (816 ) 363-370 7 Fax : (402)504-100 5 Fax:(210)579-657 7TECHNOLOGIES . 1 

# Acces s Assessment Form : (Mus t b e complete dfor ever y property . Informatio nmus t b e obtaine dfromapropert y wal k thru , no t given by owner ) I s th e propert y stucc o o r asbestos ? I f

yes , i s an y ofth e stucc o o r asbesto s damage do r cracked ? I f

yes , sto p a s w e can' t stabiliz e thi s property . I t require s specia l preparatio n techniques . I t wil l b e returne dt o EP A an dthe y wil l assig na t alate r date . Doe s thi s propert y requir e lot s o f scrapping ? Doe s thi s propert y requir e alif t o r scaffoldin g t o reac huppe r levels ? Doe s thi s propert y hav e lot s o f plant s o r item s i narea s wher e paintin g i s required ? W o Doe s thi s propert y hav e an y significan t structura l damage ? I f

yes , EXPLAIN ?

808 0 War d Parkway , Suit e 40 5 250 5 N . 24* ^ Street . Suit e 30 8 424 2 Medica l Drive , Suit e 425 0 Kansa s City , M O 6411 4 Omaha , Nebrask a 6811 0 Sa n Antonio , TX 7822 9 Phone : (816 ) 363-370 3 Phone : (402)504-100 4 Phone : (210)822-958 8 Fax : (816 ) 363-370 7 Fax : (402)504-100 5 Fax : (210 ) 579-657 7TECHNOLOGIS T 1 

## Doe s thi s propert y hav e agarage ? I f

yes , describ e locatio no f garage . Doe s thi s propert y hav e aluminu msiding ? I f

yes , i s i t origina l factor y finis ho r ha s i t bee npainte dover ? Doe s thi s propert y hav e an y othe r typ e o f structura l components ? (Le . roo f shingle s a s siding) ? 

## j ^ o I f

yes , EXPLAIN ? I s thi s propert y vacan t o r occupied ? Ar e ther e an y pet s a t thi s property ? Ar e ther e an y lo w hangin g powe r lines ?

808 0 War d Parkway , Suit e 40 5 250 5 N . 24* ^ Street , Suit e 30 8 424 2 Medica l Drive , Suit e 425 0 Kansa s City , M O 6411 4 Omaha , Nebrask a 6811 0 Sa n Antonio , TX 7822 9 Phone : (816 ) 363-370 3 Phone : (402)504-100 4 Phone : (210)822-958 8 Fax : (816 ) 363-370 7 Fax : (402)504-100 5 Fax : (210 ) 579-657 7OOLOGIES . INC . 

## PAIN T MATCHIN GFORM : 1 . T O B EFILLE D OUT ONL Y I FMATCHIN GCOLO R PROPERTY ADDRESS : 7. S ( 8 " YO/^n U ^ ^ 

## BVID : 2.*^S2," 7 Th e following note s ar e for th e benefit o f

pain t crew only . Locatio n Sidin g Soffi t • Fasci a Come r Tri m Windo w Trim s Door Trim s Front PorchCeilin g Front Porc hCeilin g Beam s Front PorchFloo r Fron t PorchRailing s Front PorchStep s Sidin g Baseboard s Foundatio n



## *?i?a c <;4-ep< ; 4 - \



## H ^ (p^C(^3 c Pain t Descriptio n 

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• I UNDERSTAN D SHERWI NWILLIAMS WIL LMATC H M Y CURREN T COLORS . 4 Homeowner signature : 

# A ry ZS l Date : Aflf l lo f

808 0 War d Parkway , Suit e 40 5 250 5 N . 24 " Street , Suit e 30 8 424 2 Medica l Drive , Suit e 425 0 Kansa s City , M O 6411 4 Omaha , Nebrask a 6811 0 Sa n Antonio , TX 7822 9 Phone:(816)363-370 3 Phone : (402)504-100 4 Phone : (210)822-958 8 Fax : (816 ) 363-370 7 Fax : (402)504-100 5 Fax : (210 ) 679-667 7TBCHNCaXXilES, ] 

## NEIGHBORHOO D PROPERT Y ACCES S FORM I S THEREA NEIGHBORIN GPROPERT Y THA T NEED S T O B EACCESSED ALONG WIT H ASSIGNE D PROPERT Y T O COMPLET ESTABILIZATIO NPROCESS ? 

# 1^ 0 I FI T IS , GE T ACCES S FRO M ALLREQUIRE D NEIGHBORHOO D PROPERTIES .

808 0 War d Parkway , Suit e 40 5 250 5 N . 24* " Street , Suit e 30 8 424 2 Medica l Drive , Suit e 425 0 Kansa s City , M O 6411 4 Omaha , Nebrask a 6811 0 Sa n Antonio , T X 7822 9 Phone : (816 ) 363-370 3 Phone : (402)504-100 4 Phone : (210)822-958 8 Fax : (816 ) 363-370 7 Fax : (402)504-100 5 Fax : (210 ) 579-657 7TECHNOLOGIBSk ] 

## PRE-STABILIZATIO NPROPERT Y SAFET Y ASSESSMENT FORM 

# 2.5) 9 yy)dip U s- f PROPERT Y ADDRESS : BVID/SAID : ^WO ^ T PRUDEN T ASSESSMENT REPERSENTATIVE : 

# ^ M A^l ^ REPERSENTATIV EREMARKS/FINDINGS : (POWER-LINEPROXIMIT Y T O PROPERTY , SCAFFOLDING / LADDERS / LIFT S NEEDED , UNSAF EAREAS , UNSAF ENEIGHBORHOOD...ETC. )

808 0 War d Parkway , Suit e 40 5 250 5 N . 24" " Street , Suit e 30 8 424 2 Medica l Drive , Suit e 425 0 Kansa s City , M O 6411 4 Omaha , Nebrask a 6811 0 Sa n Antonio , T X 7822 9 Phone : (816 ) 363-370 3 Phone : (402)504-100 4 Phone : (210)822-958 8 Fax : (816 ) 363-370 7 Fax : (402)504-100 5 Fax : (210 ) 579-657 7TECHNOLOGIES . IN C 

## Checklis t fo r th e Worksit e Hazar dAnalysi s Address : 

# ,^^1 ^ Crew : Date :



# L^o^bi- ^

::r^8 0 War dParkwayWSuit e 40 5 250 5 N . 24* " Street , Suit e 30 8 424 2 Medi ^ Drive , Suit e 425 0 /-Kansa s City , IVI O 6-111 4 Omaha , Nebrask a 6811 0 'nAntonio , T X 7822 9 -^ Phone : (816 ) 363-370 3 Phone : (402)504-100 4 Pfione : (210)822-958 8 Fax : (816 ) 363-370 7 Fax : (402)504-100 5 Fax : (210 ) 579-657 7Vii3 i

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>Douglas Count y Accoun t Informatio n Pag e 1 of 2 Dougla s County , Nebrask a Propert yRecor d - R200345000 0 Prin t Repor t NE W Featur e - Parce l Dimension s availabl e @ scal e 0-5 0 f t wes t of 52n d S t - VJe W O H Ma p Infomiatio n i s vali d a s o f 2009-9-1 5 Treasurer' s Ta xRepor t Ne wFeatur e • • r * T » Aut o Sale s Searc h Owne r EL-HAJJA R FAYE Z ETA L 

# h^' B 

# ­ ^ ) i 1 (. ^ 1171 8 MEREDIT H AV E OMAH AN E 68164-000 0 .ji/Z _ 

# A ^ o^T T ~( / Propert yInformatio n _ ^ 

### -f ^ .0 ­ ^ Ke yNumber : 034 5 OOO O 2 0 Accoun t Type : Residentia l Parce l Number : 200345000 0 Parce l Address : 251 8 MAPL E g T OMAH AN E 68111-000 0 Lega l Description : PATRICK S - AS - AD D LO T5 BLOC K8 W 3 0 F T3 0 X 12 0 Valu e Informatio n Lan d improvemen t Tota l 200 9 $ 1,900.0 0 $ 15,900.0 0 $ 17,800.0 0 200 8 $ 1,900.0 0 $ 17,400.0 0 $ 19,300.0 0 200 7 $ 1,900.0 0 $ 17,400.0 0 $ 19,300.0 0 200 6 $ 1,900.0 0 $ 17,400.0 0 $ 19,300.0 0 200 5 $ 1,900.0 0 $ 17,400.0 0 $ 19,300.0 0 200 4 $ 1,900.0 0 $ 9,200.0 0 $ 11,100.0 0 Sale s Informatio n Sale s Date : 2003-09-2 5 Dee d Type : W D Book : 200 3 Page : 19666 0 Price : $ 20,000.0 0 Grantor : JAME S HOLMO N ETA L Grantee : FAVE Z EL-HAJJA R ETA L Valid/Invalid : Vali d Exclusio n Reason : Lan d Informatio n Acre s S F Unit s Dept h Widt h Vacan t 0.0 8 3600. 0 1. 0 120. 0 30. 0 N o Improvemen t Informatio n http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R2003450000 9/16/2009Dougla s Count y Accoun t Infonnatio n Pag e 2 of 2

251 8 Maple

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U I RANCH isTSJs^.n . Mj rit a !mMCLIC KT O ENLARG E IMAG E CLIC KT O ENLARG E IMAG E Squar e Footage : 1075. 0 Percen t Complete : 100.0 % Perimete r 0. 0 Quality : Fai r Uni t Type : Condition : Poo r

Buil t As : 1 1/ 2 Stor yUnfi n Cond o Squar e Footage : 0. 0 HVAC : Centra l Ai rt o Ai r Rooms : 5. 0 Exterior : Fram e Sidin g Units : 1. 0 Interio r Drywal l Baths : 1. 0 Roo f Cover : Compositio n Shingl e Bedrooms : 2. 0

Roo f Type : Gabl e Stories : 1. 5 Floorcover : Allowanc e Foundation : Bloc k Sprinkle rSquar e Footage : 0. 0 Yea rBuil t Yea r Remodele d Percen t Remodele d Adjuste d Yea r Buii t Physica l Ag e 188 5 0 % 188 5 12 4 Detai l Typ e Detai l Descriptio n Unit s Applianc e Allowanc e 1. 0 Basemen t Bsmn t Bloc k 8 ft 901. 0 Fixtur e Bas e Fixture s 1. 0 Fixtur e Bat h Ful l 1. 0 Porc h Sla b Roo f Cei l 172. 0

http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R200345000 0 9/16/200 9

### 40L0GIBS.INC . 2 . T O B EFILLE D OU T ONL Y I FCHANGIN GCOLO R PROPERT Y ADDRESS : BVID : Locatio n Pain t Descriptio n Pain t Ye s Pain t N o Sidin g Soffi t Fasci a Come r Tri m Windo w Trim s Door Trim s Front PorchCeilin g Front PorchCeilin g Beam s Front PorchFloo r Front PorchRailing s Front PorchStep s Sidin g Baseboard s Foundatio n



### 1 AGRE ET O TH ECOLOR S INDICATE D ABOVE . I UNDERSTAN T THA T I CANNO T CHANG ETH ESELECTE D COLOR S LATERONA S PRUDEN T WOULD HAV EPURCHASE D TH EPAIN T SPECIFICALL Y FO RTHE REFERENCE D PROPERTY . ALS O I UNDERSTAN D THA T COLOR S SELECTE D MAY NO T LOOK . EXACTL Y A S IT I S SHOWNONSWATCHE S AFTE R PAINTIN GONM Y PROPERTY . Homeowne r signature : Date : 808 0 War d Parlcway , Suit e 405 2506 N . 24* ^

Street , Suit e 308 4242 Medica l Drive , Suit e 426 0 Kansas city , MO 6411 4 Omaha , Nebrask a 6811 0 Sa n Antonio . T X 7822 9 Phone:(816)363-370 3 Fax : (816) 363-3707 Phone : (402)504-100 4 Fax : (402)504-100 5 Phone : (210)822-968 8 Fax : (210 ) 679-667 7

### 40L0GIBS . INC . 2 . T O B EFILLE D OU T ONL Y I FCHANGIN GCOLO R 

## PROPERT Y ADDRESS : £ 1 $ 1 Y nC^PI 

# BVID : MUy Locatio n Sidin g Soffi t Fascia Come r Tri m Windo w Trims Doo r Trims Fron t Porc hCeiling Fron t Porc hCeiling Beam s Pain t Descriptio n 

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### I AGRE ET O THECOLOR S INDICATE D ABOVE . I UNDERSTAN T THA T I CANNO T CHANG ETH ESELECTE D COLOR S LATE RO NA S PRUDEN T WOUL D HAV EPURCHASE D TH EPAIN T SPECIFICALL Y FO RTH E REFERENCE D PROPERTY . ALS O I UNDERSTAN D THA T COLOR S SELECTED MAY NO T LOO K EXACTL Y A S I T I S SHOWNO NSWATCHE S AFTE R PAINTIN GO NM Y PROPERTY . Homeowne r signatiire^^,,^^^ ^ 

### Date : f^<{\uglo ^ 808 0 War d Parlcway , Suit e 40 5 250 5 N . 24* " Street , Suit e 30 8 424 2 (Medica l Drive , Suit e 425 0 Kansa s City , M O 6411 4 Omaha , Nebrask a 6811 0 Sa n Antonio , TX 7822 9 Phone:(816)363-370 3 Phone : (402)504-100 4 Phone : (210)822-958 8 Fax:(816)363-370 7 Fax : (402)504-100 5 Fax : (210 ) 579-657 7

# Curren t Sampl e Pre-Renovatio n For m Effectiv e unti l Apri l 2010 . Confirmatio n o f Receip t o f Lea d Pamphle t p

^

I hav e receivec i a cop yo f th e pamphlet , Renovat e Right : importan t Lea d Hazar d ' Informatio n fo rFamilies , Chil d Car e Provider s an d School s informin g m e o f th e potentia l ris k o f th e lea d hazar d exposur e fro m renovatio n activit yt o b e performe d i n m ydwellin g unit . 1 receive d thi s pamphle t befor e th e wor k began . Printe d nam e o f recipien tDat e 

# yy^ir ^ c bignatur e o f recipien t Self-Certificatio n Optio n (fo rtenant-occupie d dwelling s only ) — I f th e lea d pamphle t wa s delivere d bu t a tenan t signatur e wa s no t obtainable , yo u maychec k th e appropriat e bo xbelow . •Refusa l t o sig n — I certif ytha t I hav e mad e a goo d fait h effor t t o delive rth e pamphlet . Renovat e Right : Importan t Lea d Hazar d Informatio n fo rFamilies , Chil d Car e Provider s an d Schools , t o th e renta l dwellin g uni t liste d belo wat th e dat e an d tim e indicate d an d tha t th e occupan t refuse d t o sig n th e confirmatio n o f receipt . I furthe rcertif ytha t I hav e lef t a cop yo f th e pamphle t a t th e uni t wit h thepccupant . ijM^availabl e fo rsignatur e —I certifytha t I hav e mad e a goo d fait h effor t t o delive rth e pamphlet , Renovaf e Right : Importan t Lea d Hazar d Informatio n fo r Families , Chil d Car e provider s an d Schools , t o th e renta l dwellin g uni t liste d belo wan d tha t th e occupan t wa s unavailabl e t o sig n th e confirmatio n o f receipt . I furthe rcertifytha t I hav e lef t a cop yo f th e pamphle t at th e uni t b yslidin g i t unde rth e door . Printe d nam e o f perso n certifyin g / ) Attempte d deliver y dat e an d tim e lea d pamphle t deliver y Signatur e o f perso n certifyin g lea d pamphle t deliver y

Uni t Addres s Not e Regardin g Mailin g Optio n —A s a n alternativ e t o deliver yi n person , yo u maymai l th e lea d pamphle t t o th e owne rand/o rtenant . Pamphle t mus t b e maile d a

t leas t 7 day s befor e renovatio n (Documen t wit h a certificat e o f mailin g fro m th e pos t office) .TECEflNOLOGEBS . INC . 

## Pruden t Propert yCiose-Ou t For m (Lead-Base d Pain t Stabiiization ) SAID :A^g2 1 : . Propert yAddress : c^S^g . MdPJg . ^ X Owner' s Name : x ^ jonc i ^CY^WC*' ^ S.N O Performanc e Standards/close-Ou t Criteri a Ye s N O 1 Wa s th e entir e structure(s ) painte d wit h th e exceptio n o f th e stated , exclude d areas ? Thi s woul d includ e paintin g o f othe rassociate d feature s includin g fascia , eaves , siding , al l trim , porches , bo x \ ^ beams , columns , rails , an d exterio rsurface s o f garages . 2 Wa s al l scrapin g an d othe rpreparatio n wor k complete d satisfactorily ? \y ^ 3 Wer e al i require d area s o f th e structure(s ) prime d a s neede d an d • ^ painte d wit h tw o to p coats ? 4 Ar e al l o f th e area s wher e contaminate d material s hav e bee n spille d thoroughl yvacuumed / cleaned ? ^ 5 Di d th e contracto rcollect/vacuu m al l fallin g an d scrape d pain t chip s o n th e entir e property , roadways , alleyways , publi cacces s area s ^ an d als o remov e an yothe rgenerate d debris ? 6 I s th e gras s are a tha t surround s th e structure(s ) i n reasonabl ygoo d 

# . y condition ? 7 Wa s th e pain t product s utilize d equivalen t t o a 3 0 yea r ^ product/quality ? 8 Ar e al l item s suc h a s polyethylen e sheeting , ladders , pain t brushes , ^ cones , barrie rtap e et cproperiy , removed ? 9 I s ther e an yevidenc e o f propert ydamag e tha t wa s don e b yth e contractor ? An ypropert ydamag e need s t o b e complete d prio rt o ^ th e EP AClose-Ou L 1 0 Ar e ther e an ypropert yitem s tha t wer e temporaril yre-locate d b yth e \ ^ contracto rtha t nee d t o b e move d back ? 1 1 Ar e ther e an y(known ) lingerin g issue s wit h th e propert yowner(s ) tha t hav e bee n lef t unresolved ? V- / 1 2 Othe rConsiderations ? Propert yOwne rDiscussions ? Additiona l u / Wor k tha t i s Require d Pruden t Representativ e Signature : Date : Propert yOwne rSignature : 

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## Date : lo/p-j^ ^ 808 0 War d Parlcway , Suit e 40 5 250 5 N . 24* " Street . Suit e 30 8 424 2 Medica l Drive . Suit B 42S 0 Kansa s City , M O 6411 4 Omaha , Nebrask a 6811 0 Sa n Antonio . T X 7822 9 Phone : (816 ) 363-370 3 Plione : (402)504-100 4 Phone : (210)822-958 8 Fax:(816)363-370 7 Fax : (402)504-100 5 Fax : (210 ) 579-657 7TECHNOIJOGnS l INC . 

## EP ACiose-Ou t For m (Lead-Base d Pain t Stabilization ) BVID : ^^^X ^ Propert yAddress : i p o I o i PMotp U ^ h Owner' s Name : F^V^ ^

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WAJJ^CJ U Performanc e Standards/close-Ou t Criteri a Was th e entir e structure(s ) painte d wit h th e exceptio n o f th e stated , exclude d areas ? Thi s woul d includ e paintin g o f othe rassociate d feature s includin g fascia , eaves , siding , al l trim , porches , bo x beams , columns , rails , an d exterio rsurface s o f garages . Was al l scrapin g an d othe rpreparatio n wor k complete d satisfactorily ? Wer e al l require d area s o f th e structure(s ) prime d a s neede d an d painte d wit h tw o to p coats ? Ar e al l o f th e area s wher e contaminate d material s hav e bee n spille d thoroughl yvacuumed / cleaned ? Di d th e contracto rcollect/vacuu m al l fallin g an d scrape d pain t chip s o n th e entir e property , roadways , alleyways , publi cacces s area s an d als o remov e an yothe rgenerate d debris ? I s th e gras s are a tha t surround s th e structure(s ) i n reasonabl ygoo d condition ? Was th e pain t product s utilize d equivalen t t o a 30 yea r product/quality ? Ar e al l item s suc h a s polyethylen e sheeting , ladders , pain t brushes , cones , barrie rtap e et cproperi yremoved ? I s ther e an yevidenc e o f propert ydamag e tha t wa s don e b yth e contractor ? An ypropert ydamag e need s t o b e complete d prio rt o th e EP AClose-Out . Ar e ther e an ypropert yitem s tha t wer e temporaril yre-locate d b yth e contracto rtha t nee d t o b e move d back ? Ar e ther e an y(known ) lingerin g issue s wit h th e propert yowner(s ) tha t hav e bee n lef t unresolved ? Othe rConsiderations ? Propert yOwne rDiscussions ? Additiona l Wor k tha t i s Require d 

### S.N O 1 2 3 4 5 6 7 8 9 1 0 1 1 1 2 

### Ye s 

# y y A / / / 

## y A N O

A A / /



### EP ACOR/ Representativ e Signature . 

## Date : lljiU/o 1